Saha Single Payer 101 NURSING Final

The shortcomings of the ACA prove It’s Time for a

Single-payer Healthcare SystemAnand Saha

MD Candidate, East TN State Quillen College of MedicineMPH Candidate, University of Memphis School of Public Health

Board member, Physicians for a National Health Program

Physicians for a National Health Program (PNHP)

• 20,000+ physicians, nurses, public health workers and other professionals

• We believe access to high-quality health care is a human right

• We support Single-payer “Improved Medicare for All”• Medical care should be privately delivered but

publicly funded • Health care should be provided equitably as a

public service • Health care should not be bought and sold as a

commodity

“Triple Aim” of Good Healthcare Systems

QUALITY of patient care

Minimize COSTBetter

POPULATION HEALTH outcomes

The Most ExpensiveHealth Care System In the World

Data are for 2013 or nearest yearUS$ Purchasing Power Parity

OECD data accessed Nov 30 2015

Annual per capita dollars spent on health care

United

State

s

Norway

Swed

en

Denmark

Luxem

bourg

Belgium

Austral

ia

Icelan

d

OECD AVER

AGE

New Zea

land

Italy

Portu

galIsr

aelKo

rea

Slovak

Repub

licChile

Polan

dTu

rkey

$0

$2,000

$4,000

$6,000

$8,000

$10,000USA: $8,713

Average: $3,453

US Spending per Capita

Data are for 2010Sources: OECD 2012; Health Affairs 2002 21(4)88

Japan UK Sw

Franc

e Ger Ca US $-

$2,000

$4,000

$6,000

$8,000

$10,000

$3,

040

$3,

430

$3,

760

$3,

970

$4,

340

$4,

440

5290

2940

Total US Public US Private

2010

hea

lthca

re sp

endi

ng p

er c

apita

USA’s public spending exceeds everyone’s total

spending!

Health Insurance Is Increasingly Unaffordable

http://www.commonwealthfund.org/interactives-and-data/chart-cart/presidents-column/costs-of-failure/average-family-premium-as-a-percentage-of-median-family-

incomeAccessed Feb. 25, 2016

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

0%

5%

10%

15%

20%

25%

30%

12%13%

14%16%

17%18% 18% 18% 18% 18%

19% 19% 19%20% 20%

21% 21%22% 22%

23%24%

Average Family Premium as a Percentage of Median Family Income

We Have Plenty of Administrators

Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of CPS

Managers shown as moving average of current year and two previous years

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

2003

2006

2009

2012

2015

0%500%

1000%1500%2000%2500%3000%3500%

Managers Physicians

Growth since 1970

$0.31 of healthcare dollar is spent onnon-value added care

Medical overhead, administration, and insurance profits

Medical care

31%69%

Woolhandler, et al “Costs of Health Administration in the U.S. and Canada,”

NEJM 349(8) Sept. 21, 2003

$300 monthly premium $93 monthly waste

16%84%

United States

Canada

Health Insurance CEO 2014 Pay

Source: SEC filings

Mark Bertolini

Joseph Swedish Michael Neidorff

David Cordani Steve Hemsley Bruce Broussard

AetnaAnnual Comp:

$15.0 MPay/Weekday:

$57,745

CignaAnnual Comp:

$27.2 MPay/Weekday:

$104,479

UnitedAnnual Comp:

$66.1 MPay/Weekday:

$254,328

HumanaAnnual Comp:

$13.1 MPay/Weekday:

$50,319

WellpointAnnual Comp:

$8.1 MPay/Weekday:

$31,016

CenteneAnnual Comp:

$ 28.1 MPay/Weekday:

$107,962

30 Million Will Remain Uninsured

Graphic by the New RepublicCBO May 2013 Update on ACA

CBO Feb 2014 Update on Budget and Economic Outlook

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

0

10

20

30

40

50

6057 57 57 56 56 55 55 56 56 56 56 5755

4537

31 30 30 30 30 31 31 31 31

Without ACA With ACA

Uninsured (Millions)

Why Are So Many Uninsured?

KCMU Analysis of 2013 NHIS

No Offer11.2%

Aged Out / Left School

8.8%

No Need1.5%

Lost Job29.4%

Insurance Not Af -fordable31.6%

Other17.4%

Note: Data are for 2013 or most recent year availableSource: OECD, 2015

Infant MortalityDeaths in First Year of Life Per 1,000 Live Births

USA CAN FRA AUSTRL GER ITA SWE0

1

2

3

4

5

6

7

6.0

4.8

3.6 3.6 3.32.9 2.7

Note: Data are for 2013 or most recent year availableSource: OECD, 2015

Physician Visits per Capita

USA DEN UK FRA AUSTRL CAN JAP0

2

4

6

8

10

12

14

4.0 4.5 5.06.4

7.3 7.7

12.9

Life

Expe

ctan

cy a

t bi

rth

USA

Denmark

Portu

gal UK

Finlan

dNzea

l

Greece

Korea

Swed

en

Icelan

dFra

nce

Switz

Japan

767778798081828384

We’re Number 25 in Life Expectancy

2013 data from OECD accessed Nov 19 2015https://data.oecd.org/healthstat/life-expectancy-at-

birth.htm

Ultimate cost: 45,000 Annual Deaths

State Percent Uninsured

Excess Deaths

California 23.9% 5,302Texas 29.7% 4,675

Florida 26.0% 3,925New York 17.5% 2,254Georgia 23.6% 1,841

USA 15.3% 44,798Source: Wilper et al. Am J Public Health 2009.

State tabulations by author

Ultimate Cost:Personal Bankruptcy

Himmelstein, et.al. Am J Med, August, 2009

of all bankruptcies in 2007 were medical62

%had medical debts over $5,000or 10% of pretax family income

92%

had health insurance

75%

Source: Himmelstein et al. Am J Med: August, 2009

VA / Mil-itary2%Medicare

10%

Medicaid5%Unin-

sured22%

Private Insurance

60%

And Most Had Insurance!

My interpretation:

Injustice in USA’s healthcare sysyemis a human rights issue

Two Options for Reform

Double down on current system

with for-profit insurance companies and the free market.

Establish single-payer “Improved and

Expanded Medicare for All.”

–or–

The ACA: CostPros

• Accountable Care Organizations (ACOs)

Cons

• No increased bargaining power of Medicare for drugs

• No decrease in the complexity responsible for administrative waste

The ACA: AccessPros

• Can’t discriminate against women or against citizens with pre-existing conditions

• Stay on parents’ plan until 26 years old

• Approximately 19 million newly insured

Cons

• Supreme Court ruled Medicaid expansion on a state-by-state basis

Who knows…

• Established insurance exchange @ healthcare.gov

• Individual mandate (penalty if no coverage)

The ACA: QualityPros

• FREE yearly check-up & flu shot

• Insurance companies must spend at least 80-85% on patient care

• No lifetime limit on insurance payouts

Cons

• Plans with high deductibles and co-pays

Who knows…

• ”What does this mean for the patient?” – still very elusive question

Tennessee Is Not Yet Expanding Medicaid

Anticipated health impact of Medicaid expansion into current non-expansion states.Dickman S, Himmelstein D, McCormick D, and Woolhandler S. Opting out of Medicaid

Expansion: The Health and Financial Impacts. Health Affairs Blog. January 30, 2014, accessed Dec. 14 2015.

Economic impact from Commonwealth Fund

Better women’s health• 9,744 more mammograms• 18,942 more Pap smears

Better treatment of chronic diseases• 16,843 more diabetics receiving

medications• 28,381 fewer adults with depressionMany fewer preventable deaths• Between 284 and 759 fewer deaths• One or two each and every day.

TN is walking away from

$2,111,000,000

in federal funds.

Uninformed consumer:Rhetoric of “Choice”

Name Of Plan* BlueCross Bronze B02S

BlueCross Silver S07S

BlueCross Platinum P02S

Plan Type Bronze Silver PlatinumMonthly Premium $152 $224 $360

Deductible $4,000 $1,500 $0Annual Cap $6,350 $6,350 $1,500Minimum $1,819 $2,684 $4,320Maximum $8,169 $9,034 $5,820

*Actual health plans from TN Health exchange

Anand’s ACL surgery: $20,000 + Rehab 3x/week: $2,000

Federal fundsState fundsEmployers

Individuals

“Single payer”

(1 pool to pay

providers)

Credit: PNHP California chapter

Single payer is simple

Our patchwork of modelsBeveridge

ModelBismarck

ModelNational Health

InsuranceOut-of-pocket

Financing (Insurance

)Public Private Public None

Delivery (Providers) Public Private Private Private

Examples of

countries

Britain, Italy,

Scandinavia

Germany, Japan, France

Canada, Taiwan

African countries, India, S America

T.R. Reid's book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

Single Payer, “Improved Medicare for All” overview

• Public funding• 1 single pool to pay providers• Individuals pay into pool via taxes; no additional costs

• Private delivery: • Majority of healthcare providers remain private

• Healthcare is birth right; everybody in, nobody out

• Reduce administrative costs• What will administrators do all day if just 1 insurance

company??• Collectively bargain lower drug prices

“Triple Aim” of Single Payer, Improved Medicare for All

QUALITY of patient care

Minimize COSTBetter

POPULATION HEALTH outcomes

PNHP Proposal: HR 676 “Improved Medicare for

All”• Sponsored by Rep John Conyers (D-MI); 54 co-

sponsors.

Who?

• ‘Triple Aim’: Improves quality, reduces cost, expands access

What?

• Improves quality of insurance (no deductibles, copays, etc)

• Reduces costs saving $592B total annually• Cuts administrative costs by $476B annually• Cuts pharmaceutical costs by collective bargaining

$116B annually• Insures all 30 million uninsured Americans as a birth

right

How?

PNHP Proposal: HR 676 “Improved Medicare for

All”• Stop administrative waste (save ~$476B annually)

Streamline payment

• Stop profit of sufferingCreate a single risk pool

• Stop marketing wasteOffer only one plan

• Stop pharmaceutical profits (save ~$116B annually)

Collective bargaining

• Stop expensive diseases from startingIncrease prevention

• Stop rationing of health care professional choice

Free choice of providers

Credit: PNHP California chapter

Can we afford Medicare for All?

Data are for 2010Sources: OECD 2012; Health Affairs 2002 21(4)88

Japan UK Sw

Franc

e Ger Ca US $-

$2,000

$4,000

$6,000

$8,000

$10,000

$3,

040

$3,

430

$3,

760

$3,

970

$4,

340

$4,

440

5290

2940

Total US Public US Private

2010

hea

lthca

re sp

endi

ng p

er c

apita

We are paying for single payer but not getting it!

Our taxes already cover Improved Medicare for All…

3 major public HC expenditures:• Direct government payouts

• Medicare, Medicaid, VA, NIH, public health departments

• 47.8% or $1.395 trillion• Federal, state, and local tax

subsidies for healthcare• 10% or $296 billion

• Public employees’ health insurance/benefits• 6.4% or $188 billion

Himmelstein, David U., and Steffie Woolhandler. "The Current and Projected Taxpayer Shares of US Health Costs." American Journal of Public Health 0 (2015): e1-e4.

64.3%

Improved Medicare for AllMakes Economic Sense

Friedman, G. Dollars & Sense. March/April 2012

$74

$110 $153

$142 $215

$178

$ Billions

New Costs

New Savings

Medicaid Rate Adjustment

Covering the uninsured

Increased utilization (especially home

health and dental)

Gov. admin ($23B)Health insurance admin

Increased market power (better pricing on drugs and devices)

Admin costs to providers

A Fork in the Road

Source: Statistics Canada, Canadian Institute for Health Info, and

NCHS/Commerce Dept.

Health costs % of GDP

19%17%15%13%11%

9%7%5%

1960 1970 1980 1990 2000

Canada

USA

2014

USA 1971: HMO Act

Canadian Single Payer

Fully Implemented

Most Physicians Support a National Health Program.

2007 detail of surveys of random samples of US physicians.

Carroll and Ackerman. Ann Int Med 2008;148:566

PsychiatryPeds

SpecialtiesEmergency

MedGeneral Peds

General Int. MedMed

SpecialtiesFamily Med

OB-GynGeneral Surgery

Surg SpecialtiesRadiology

0 25% 50% 75% 100%Percent supporting National Health Insurance

We Can Win the Trifecta“You can have

universal coverage and good quality healthcare while still managing to

control costs… but you need

Single-Payer to do it.”Dr. William Hsiao

Harvard Health Economist

1,000+ students in 50+ chapters

170 students from 50+ schools…in Tennessee!

5th annual SNaHP SummitVanderbilt University in Nashville, TN

March 5, 2016

For more information…[email protected]

Health policy websites:• The Commonwealth Fund:

www.commonwealthfund.org• Kaiser Family Foundation: www.kff.org• Health Affairs Blog: http://healthaffairs.org/blog

/• Physicians for a National Health Program:

www.PNHP.org